Provider Demographics
NPI:1477876928
Name:KELLEY, MARY F (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6103
Mailing Address - Country:US
Mailing Address - Phone:215-829-3053
Mailing Address - Fax:
Practice Address - Street 1:330 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6103
Practice Address - Country:US
Practice Address - Phone:215-829-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP002188H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS47976Medicare UPIN